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Integration of Primary Care and Behavioral Health Tenly Pau Biggs, MSW Center for Mental Health Services Mental Health America Regional Meeting, Feb. 19, 2016 Integrated Care • What is integrated care? • “Integrated care is the systematic coordination of general and behavioral health. Integrating mental health, substance abuse and primary care services produces the best outcomes and proves the most effective approach to caring for people with multiple healthcare needs.” -SAMHSA-HRSA Center for Integrated Health Solutions, www.integration.samhsa.gov The Problem What does the data tell us? National Comorbidity Survey Replication, 2001-2003 as Reported in Druss and Walker, 2011 The Cost of Having Multiple Chronic Conditions $5,000 $4,717 $4,500 $4,032 $4,000 $3,500 $3,233 $3,000 $2,739 $2,627 $2,500 $2,000 $1,601 $1,500 $1,000 $500 $2,052 $1,999 $1,382 $751 $680 $212 $- No Costly Physical Conditions Mental Health Service Users One Costly Physical Condition Two Costly Physical Conditions Substance Abuse Service Users Three or More Costly Physical Conditions All Other Medicaid Beneficiaries SAMHSA. (2010). Mental health and substance abuse services in Medicaid, 2003: Charts and state 6 tables. HHS Publication No. (SMA) 10-4608. Medicaid Population: Data MEDICAID BENEFICIARIES WITH DISABILITIES: •45% have 3+ chronic conditions •50% have a psychiatric illness •35% have a chronic mental health/substance use disorder (MH/SUD) •60% of those with MH/SUD also have other chronic physical conditions & report fair or poor health Key Concepts of RFA SM-15005 •Healthcare spending is 60-70% higher for beneficiaries with MH/SUD and chronic physical conditions; •4-5 x more likely to be hospitalized for the top 5 most common chronic conditions (asthma/COPD, congestive heart failure, coronary heart disease, diabetes & hypertension) 7 HHS/CDC Million Hearts ® Campaign •Million Hearts® initiative will focus, coordinate, and enhance cardiovascular disease prevention activities across the public and private sectors in an unprecedented effort to prevent 1 million heart attacks and strokes by 2017 and demonstrate to the American people that improving the health system can save lives. Key Concepts of RFA SM-15005 •ABCS •Aspirin for people at risk for heart attack •Blood Pressure Control •Cholesterol Management •Smoking Cessation 8 Co-Occurrence Between Mental Illness & Chronic Health Conditions Overview of SAMHSA’s PBHCI Grant •Purpose: to establish projects for the provision of coordinated and integrated services through the co-location of primary and specialty care services in community-based mental and behavioral health settings. Key Concepts of RFA SM-15•Goal: to improve the physical health status of adults with 005 serious mental illnesses (SMI) who have or are at risk for co-occurring primary care conditions and chronic diseases. •Objective: to support the triple aim of improving the health of those with SMI; enhancing the consumer’s experience of care (including quality, access, and reliability); and reducing/controlling the per capita cost of care. 10 PBHCI Grantee Expectations • Establish projects for the provision of coordinated and integrated services through the co-location of primary and specialty care medical services in the community-based behavioral health settings • Key Concepts of RFA SM-15005 Requirements: • Provide, by qualified primary care professionals, on site primary care services and • Provide, by qualified specialty care professionals or other coordinators of care, medically necessary referrals and linkages to primary care services. 11 Expectations (Continued) • Health Home Services Categories • Care coordination • Health promotion • Comprehensive transitional care from inpatient to other settings, including appropriate follow-up • Individual and family support, which includes authorized representatives • Referral to community and social support service, including appropriate followup • Health Information Technology • Submit at least 40% of prescriptions electronically • Receive structured lab results electronically • Share a standard continuity of care record between BH providers and physical health providers; and • Participate in the regional extension center program Key Concepts of RFA SM-15005 12 PBHCI Data Collection PBHCI grantees collect the following health indicators: a. Blood pressure—semiyearly b. Body Mass Index (BMI)—semiyearly c. Waist circumference— semiyearly d. Breath CO (carbon monoxide)— semiyearly e. Plasma Glucose (fasting) and/or HgbA1c—annually f. Lipid profile (HDL, LDL, triglycerides)—annually Measuring blood pressure, cholesterol and BMI are indicators for the risk of cardiovascular disease. Plasma glucose, Hemoglobin A1c and the lipid profile are predictors of diabetes. The risk of having respiratory disease is also determined by Breath CO. PBHCI Data 2015 DATA • This data reflects all cohorts. Out of over 52,000 individual people in the data set, 15,516 had three data points of NOMS (intake, 6-months, and 12-months) Participants by Gender 0.2% 48.4% 51.4% Male Female Transgender Participants by Race and Ethnic Group Black 8% 29% Asian 6% 64% Native Haw./Alaska 3% White American Indian Participants by Age 4% 6% 21% 14% 18 - 25 26 - 34 21% 35% 35 - 44 45 - 54 55 - 64 64 > Overall Health 70 60% 60 50.7% 47.8% Percent at Risk 50 40 30 20 10 Baseline Statistically significant, p < .001 6-Month 12-Month Physical Health Outcomes: Blood Pressure (Diastolic) 50 45 44% 42% Percent At Risk 41% 40 35 30 25 Baseline Statistically significant, p < .001 6-Month 12-Month Physical Health Outcomes: Blood Pressure (Systolic) 58 57 Percent at Risk 56.5% 55.8% 56 54.9% 55 54 53 Baseline Statistically significant, p < .001 6-Month 12-Month Physical Health Outcomes: Total Cholesterol 40 37% 35 Percent At Risk 32% 30 25 20 Baseline Statistically significant, p < .001 12-Month Physical Health Outcomes: High Risk HDL 30% 27% Percent At Risk 25% 24% 20% 15% 10% Baseline Statistically significant, p < .001 12-Months Physical Health Outcomes: High Risk LDL 50% Percent At Risk 40% 35% 35% Baseline 12-Months 30% 20% 10% Not statistically significant Physical Health Outcomes: Triglycerides 46 44.5% 44 Percent At Risk 42.7% 42 40 38 36 Baseline Statistically significant in wrong direction, p < .001 12-Month Physical Health Outcomes: Breath CO 50 47.3% 47.3% 46.6% Percent at Risk 45 40 35 30 Baseline Not statistically significant 6-Month 12-Month Physical Health Outcomes: HgbA1c 35% 30% Percent At Risk 30% 25% 22% 20% 15% 10% Baseline Statistically significant in wrong direction, p < .001 12-Month Integration Works Grantee Example The Institute for Community Living (ICL) assists individuals and their families affected by mental or developmental disabilities with services and supports to improve their quality of life and participation in community living. ICL serves individuals with serious mental illness (SMI) at over 100 programs throughout New York City. The PBHCI grant focuses on three of ICL’s New York State (NYS)-licensed mental health treatment programs: • Highland Park Center (HPC), a clinic; • Personal Recovery-Oriented Services (PROS), a mental health rehabilitation program; • Rockaway Parkway Center (RPC), a clinic, all located in Brooklyn, New York. The populations served at these programs are primarily Medicaid recipients disproportionately affected by several characteristics that negatively impact health and treatment, including poverty, ethnic minority status, and high degree of medical comorbidity. HLQ – ER visits & hospital admissions EMR-Based Healthy Living Questionnaire (HLQ) This is an 18 item self-report that is not part of the PBHCI grant. However, ICL administers this questionnaire to track ER visits, hospital admissions, missed medical appointments and the desire to establish a physical health goal. The individuals (n=72) reflected below are those who have both an initial NOMs and HLQ assessments and a treatment plan with a 12 month period available for analysis. ER visits and hospital admissions for physical health and mental health reasons over time, expressed as percentage of entire cohort from initial to 12 month treatment plan^ (all=p<.05) 50% ER/PH (n=70)* 40% Hospital/PH (n=71) 30% 20% 20% 19% 14% 10% 18% 16% 8% 12% 0% Initial/Baseline 5% 6 months 11% 11% 6% 4% 12 months ^Number of reports naturally vary over time points in conjunction with length of time in services *statistically significant ER/MH (n=72)* Hospital/MH (n=72)* ER Visit for Physical Health Reasons Percentage of participants with a ER visit for physical health reasons over a 3 month period, over time: 50% All_ER/PH(N=70)* 40% 30% Blk/AA_ER/PH (n=47)* 19% 20% 10% 12% 14% 8% 0% Initial/Baseline *statistically significant 6 months 6% 4% 12 months ER Visit for Mental Health Reasons Percentage of participants with a ER visit for mental health reasons over a 3 month period, by cohort over time: 50% All_ER/MH(N=72)* 40% 30% 23% 21% Blk/AA_ER/MH (n=48)* 17% 20% 20% 18% 10% 11% 0% Initial/Baseline *statistically significant 6 months 12 months Hospital Admission for Mental Health Reasons Percentage of participants with a hospital admission for mental health reasons over a 3 month period, by cohort over time: 50% All_Hospital/MH(N=72)* 40% 30% 21% 18% 20% Blk/AA_Hospital/MH (n=48)* 17% 19% 16% 10% 11% 0% Initial/Baseline *statistically significant 6 months 12 months Evolution of PBHCI 2009 1st PBHCI FOA (aka RFA) Awarded 13 grantees SAMHSA and ASPE implement evaluation awarded to RAND 2010 ACA is passed PBHCI – awarded 43 Grantees Training and Technical Assistance Center FOA (Center for Integrated Health Solutions) for SAMHSA and HRSA 2011 PBHCI - awarded 8 grantees Health Information Technology Supplement grant – only for current grantees to receive awards funds to expand EHR Evolution of PBHCI 2012 2nd PBHCI FOA (aka RFA) Awarded 30 grantees CDC’s Million Hearts Campaign is launched 2013 PBHCI – awarded 7 grantees RAND evaluation completed – initial findings 2014 PBHCI - awarded 26 grantees 2015 3rd PBHCI FOA (aka RFA) Awarded 60 grantees 2nd PBHCI Evaluation awarded Evolution of PBHCI • 2009 – 1st FOA for PBHCI – Broad definition of integration of primary care into mental health – Data collection not as specific, for example smoking was not collected • 2012 – 2nd FOA for PBHCI – Health homes services required – Physical health data tied to CDC Million Hearts Initiative required – Meeting Health Information Technology requirements • 2015 – 3rd FOA for PBHCI – Required to have substance abuse counselor and peer wellness coach – Must use a CDC blood pressure protocol – Must use specific evidence based interventions Lessons Learned • Different models of integration • Importance of having strong leadership and partnerships for both mental health/behavioral health and primary care • Having clear expectations of all the partners involved, especially as it relates to sustainability of the program and services post grant • Having an EHR that reflects mental health and primary care, using an integrated treatment plan • Using data to demonstrate impact, especially the cost of having multiple chronic conditions and the overuse of the ER/Eds • Peers are KEY to successful program SAMHSA’S Strategic Initiatives: Leading Change 2.0, 2015 – 2018 1. Prevention 2. Health Care and Health Systems Integration 3. Trauma and Justice 4. Recovery Support 5. Health Information Technology 6. Workforce Slide 38 Strategic Initiative 2: Health Care and Health Systems Integration Foster integration between behavioral health and health care, social support, and prevention systems. Support federal, state, territorial, and tribal efforts to develop and implement new provisions under Medicaid and Medicare. Support federal, state, territorial, and tribal efforts to influence and support the efficient use of various financing models and mechanisms to address behavioral health services and activities. Finalize and implement the parity provisions in the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act, and disseminate information about parity. Foster implementation of quality indicators to advance behavioral health outcomes in the health care delivery system. Slide 39 Integration – Seeing Behavioral Health As Any Other Public Health Condition 15 BH Fundamental to Individual/Community Health •Community prevention and wellness •Recovery support •Treatment and health care (incorporated screening/brief interventions, co-located services, care management models) BH’s Impact on Healthcare Costs and Outcomes •Primary, specialty, emergency, rehabilitative care Implications for Workforce •SAMHSA’s new Strategic Initiative re workforce FY 2015 -- 2018 •Preventionists, BH and other healthcare practitioners, community services workers Service Models, Payment Structures, Demos to Achieve Better Care/Value State Innovation Models: Support for development and testing of state-based models for multi-payer payment and health care delivery system transformation Health Homes (Section 2703): Whole person care for Medicaid recipients w/specific characteristics or conditions (45 SAMHSA consultations with 25+ states) Accountable Care Organizations: Coordinating high quality care for Medicare recipients, including behavioral health care Duals Demo: Ensuring Medicare-Medicaid enrollees have full access to seamless, high quality health care that is cost effective Medicaid Emergency Psychiatric IMD Demo: Supporting higher quality care at a lower total cost by reimbursing private psychiatric hospitals Medicaid Innovation Accelerator Program (to transform clinical care): Focusing on payment and service delivery reforms to improve health and quality of care for Medicaid beneficiaries; priority area – substance use disorders (SUDs) Primary Care/Behavioral Health Integration: Federal Initiatives 16 OASH: Co-morbidity working group SAMHSA’S Primary/BH Integration (PBHCI): Physical health of adults w/ SMI and TA for bi-directional integration (Center for Integrated Health Solutions, w/ HRSA) Primary Care/Addiction Services Integration (PCASI): Proposed for FY 2015 HRSA FQHCs: Integrating BH screening, brief intervention. and treatment into primary care settings Million Hearts: Wrapping BH into efforts to address ABCS AHRQ Center for Integration Models: Developing models of integrated BH care in primary care settings CMMI Innovative Financing Models for Integration: Grants to test models using SAMHSA and AHRQ indicators and TA Medicare Accountable Care Organizations (ACOs): Payment for integrated care & outcomes (ASPE tracking impacts for BH) Specific SAMHSA/Medicaid Collaboration 18 Informational Bulletins: Medication Assisted Treatment (MAT); coverage/service design of BH services for youth with serious emotional disturbance (SED); trauma-focused services; prevention and early identification of MH and SU conditions; and strengthening management of psychotropic medications for vulnerable populations – others in process . . . Ongoing Interactions: Payment rules; waiver consultation; state plan amendments; regulation review; quality measures; same day billing guidance; and parity Section 223 of the Protecting Access to Medicare Act of 2014: SAMHSA developing criteria for Certified Community Behavioral Health Clinics (CCBHCs) and managing state planning grants; CMS developing prospective payment system; ASPE to evaluate outcomes Certified Community Behavioral Health Clinics (CCBHC) Timeline Oct. 2015 – Planning Grants awarded to 24 states Oct. 2015-Oct. 2016 – Technical assistance provided to 24 states by SAMHSA, CMS, and ASPE. Oct. 2016 – Applications due to participate in demonstration* January 2017 – Deadline to select eight states to participate in two-year demonstration *Must have a planning grant to be eligible for the demonstration program Slide 44 Certified Community Behavioral Health Clinics (CCBHC) Protecting Access to Medicare Act (sec.223 – demonstration program–Excellence in Mental Health Act) $25 M.- planning grants to develop applications to participate in 2 yr. pilot Only 8 states selected 90% Federal Medical Assistance Percentages Must develop Prospective Payment System for Reimbursing CCBHC’s Slide 45 SAMHSA Updates & Resources UPDATES & RESOURCES Implementation of Agency Priorities Prevention Underage drinking Report to Congress on State Underage Drinking Prevention Activities: scientific research on adolescent alcohol use. Integration Health Care & Health Systems Integration Payment systems work in progress Value-Based Purchasing (VBP) & Merit-Based Incentive Payment Systems (MIPS) to align SAMHSA’s priorities in coordinated are with CMS CMMI’s development of rules authorized by MACRA legislation. Goal to coordinate BH services with future provider payment systems. Trauma and Justice ACA Enrollment Available on CMS website: SAMHSA Criminal Justice Enrollment Toolkit for special population enrollment Recovery Support Homelessness Administration's commitment to providing permanent supportive housing and support community integration for people with long-term services & support needs through cost-effective, evidence- based solutions. With new programs aimed at strengthening state-level collaboration between health & housing agencies Implementation of Agency Priorities (cont.) Million Heart Campaign CDC’s Million Hearts Campaign focused on cardiovascular diseases among individuals w/ BH disorders. Campaign centered on smoking cessation Health Information Technology 42 CFR Part 2 Interested in area patient confidentiality and restrictions on disclosure in the regulation apply to third party payers with regard to records disclosed to them by federally assisted programs (2.12(d)(2)) Emerging Issues & Opportunities GAO Report on SAMHSA’s MH Grants Management (including CDP) Handbook is completed and staff training is ongoing Clozapine guidelines & REMS new guidelines addressing safety concerns, neutropenia, and REMS to reduce the administrative burden Workforce Development National Child Trauma Stress Network Learning Center’s New Product Trauma & Intellectual Developmental Disabilities Toolkit “The Road to Recovery Supporting Children with Intellectual Developmental Disabilities Who Have Experienced Trauma” http://nctsn.org/products/children-intellectual-and-developmentaldisabilities-who-have-experienced-trauma [Note: You will need to create an account or log in to download the document] 49 Updated in 2016 Opioid OD Prevention Toolkit Download SAMHSA's updated Opioid Overdose Prevention Toolkit, now including information on the first nasal spray version of naloxone hydrochloride approved by the FDA. http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf Equips health care providers, communities and local governments with material to develop practices and policies to help prevent opioid-related overdoses and deaths. Addresses issues for health care providers, first responders, treatment providers, and those recovering from opioid overdose. 50 Conversion Therapy Report 51 Download New Resource Apps Launch of New SAMHSA+HRSA+ACF Center: Infant and Early Childhood Mental Health Consultation Senior Center Toolkit to Promote Emotional Health and Prevent Suicide SAMHSA Handbook Recovery After a Suicide Attempt Great New Free Apps! Suicide Prevention for Providers Prevent Bullying Data & Health Information… Treatments & Recovery… Naltrexone and 223* (*Certified Community Behavioral Health Clinics) •